Inpatient Mental Health Treatment Research Articles

The Role of Providers in Mental Health Services Offered to American-Indian Youths

The Role of Providers in Mental Health Services Offered to American-Indian Youths

Consumer satisfaction with inpatient mental health treatment in the Department of Veterans Affairs.

This study used hierarchical linear models to analyze post-discharge data among 17,130 veterans who received inpatient VA mental health services between 1995 and 2001, in order to determine whether changes in mental health service affected inpatient satisfaction. In models without covariants, half the satisfaction measures increased while the other half indicated no significant change. After adjusting for changes in patient characteristics, however, nine measures indicated no change and seven showed significant declines. Demonstrating the importance of risk-adjustment, satisfaction appeared to increase over time prior to risk adjustment, but declined after adjusting for changes in patient characteristics that were associated with patient satisfaction.

Factors affecting mental illness hospitalization rates: analysis of state-level panel data

Previous studies have shown that social conditions such as poverty may place large segments of the population at greater risk for mental illness. However, most studies have been very limited in time and scope. This study involves a state-level statistical analysis of economic and demographic factors that may influence rates of clients receiving inpatient mental health treatment in all organizations (excluding prisons) for selected years over a 12-year time period spanning most of the 1980s through the mid-1990s. Explanatory factors in our model include poverty, real per capita income, unemployment rate, age, race, education, and region-wide effects. Regression results indicate that poverty rates, real per capita income, and percent of the population age 20–24 are all significant and positively associated with the rate of clients receiving inpatient mental health treatment. Another finding of this study is that after accounting for all of the above factors, there still remain significant differences across Census Divisions in hospitalization rates for mental illness. For example, the Middle Atlantic states, East North Central states, and Pacific states have the highest share of inpatients and the New England states, Mountain states, and East South Central states have the lowest share of inpatients.

Shifting to outpatient care? Mental health care use and cost under private insurance.

Concern over rising health care costs has put pressure on providers to reduce costs, purportedly by reducing inpatient care and increasing outpatient care. Inpatient and outpatient claims were analyzed for adult users of mental health services (180,000/year on average) from a national study group of 3.9 million privately insured individuals per year from 1993 to 1995. Costs and treatment days per patient were compared across diagnostic groups and stratified by whether patients were hospitalized. Inpatient mental health costs fell $2,507 (30.4%) over the period, driven primarily by decreases in hospital days per patient per year (19.9%), with smaller changes in the proportion of enrollees who received inpatient care (increase of 0.8%) and a decrease in per diem costs (9.1%). Outpatient mental health costs also declined over the period, falling 13.6% for patients also using inpatient services and 14.6% for patients receiving only outpatient care. Patients whose primary diagnosis was mild to moderate depression saw the largest decreases in inpatient cost per patient (42.8%); those diagnosed with schizophrenia experienced the smallest decrease (23.5%). For patients using outpatient services only, those diagnosed with substance abuse experienced the largest decrease in costs (23.5%); those diagnosed with schizophrenia experienced the smallest decrease (8.6%). Substantial cost reductions for mental health services are primarily a result of reductions in inpatient and outpatient treatment days. Declines in inpatient service use were not accompanied by increases in outpatient service use, even for severely ill patients requiring hospitalization. Managed care has not caused a shift in the pattern of care but an overall reduction of care.

Changes in Inpatient Mental Health Utilization and Costs in a Privately Insured Population, 1993 to 1995

Concerns over rising health care costs have led to pressure on health care providers to reduce inpatient costs. Inpatient claims data were analyzed for adult users of mental health services (n = 45,579) from a national sample of over 3.8 million privately insured individuals between 1993 and 1995 from the MarketScan database. Costs and annual hospital days per treated patient were compared across diagnostic groups and plan types. Inpatient mental health costs fell 30.5% over the period, driven primarily by decreases in the number of hospital days per treated patient per year (-20.0%), with smaller changes in the proportion of enrollees who received care (-0.2%), and per diem costs (-13.1%). Patients whose primary diagnosis was mild/moderate depression saw the largest decrease in costs per treated patient (44.5%), and those diagnosed with schizophrenia experienced the smallest decrease (23.5%). There was no evidence of substitution of medical for psychiatric care. Inpatient cost reductions have been substantial and are primarily caused by reductions in the number of inpatient mental health treatment days per treated patient. Further research is needed to evaluate the impact of these changes on outcome, quality of care, and patient satisfaction.

The public sector and mental health parity: time for inclusion.

BACKGROUND: In the United States, there is an uneasy division of responsibility for financing mental health care. For most illnesses, employer-sponsored health insurance and the large federal health insurance programs (Medicare, Medicaid) cover the costs of care. However, most employer-sponsored plans and Medicare provide only limited coverage for treatment of mental illness. A possible cause and result of this limited coverage in mental health is that states, and in some cases local (county) governments, finance a separate system of mental health care. This separate "public mental health system" provides a "safety net" of care for indigent individuals needing mental health care. However, there are potential negative consequences of maintaining separate systems. Continuity of treatment between systems may be impaired, and costs may be higher due to duplicate administrative costs. Maintaining a separate system managed by government may exacerbate the stigma associated with mental illness treatment. Most significantly, since eligibility for care may be linked to poverty status, and since having a serious mental illness may preclude regaining private coverage, maintaining a separate system may contribute to the poverty rate among persons with mental illnesses. AIMS OF THE PAPER: These potential problems have not been widely considered, perhaps because other problems and controversies in mental health care have captured our attention. In particular, controversies over deinstitutionalization in mental health have dominated the policy debate, especially when linked to related problems. These have included conflicts over authority and financial responsibility among federal, state and local governments, sensationalized media coverage of incidents involving people with mental illness, problems with siting community facilities, concern about mental illness among prisoners and the like. However, with the substantial reform of public mental health care in some states and localities, it is now possible to consider the implications of public and private integration. This paper considers such an approach. METHODS: This paper addresses the question of public and private integration, considering the state of Ohio as a case study. Ohio is a large state (population 11.2 million) and shares demographic, cultural and political characteristics with many other states. Ohio's successful experience implementing community mental health reform makes it a good candidate to use in evaluating issues in the potential integration of insurance-paid and public mental health care. RESULTS: The analysis indicates that the resources now used in Ohio's public system may be sufficient to support insurance financing of inpatient and ambulatory mental health treatment (the types of health care usually paid by insurance) while maintaining supportive services (e.g. housing, crisis care) as a residual safety net. DISCUSSION: At the current time, these resources are in state and local mental health budgets, and in the Medicaid program that finances health care for low income and disabled individuals. The analysis indicates that the aggregate level of resources expended on inpatient and ambulatory mental health treatment are substantially greater than expenditures for such care in an insurance plan for Ohio State employees. A substantial limitation of the analysis is that it is not possible to compare the need for care in a relatively healthy employed population versus a poor and disabled population. CONCLUSION: The paper concludes that there are substantial structural, economic and social problems associated with the "two-tiered" system of commercial/employer-paid insurance and public mental health care in the United States. Examining data from one state's public system, the paper further concludes that it might be feasible to finance a single system of acute and ambulatory mental health benefits, if public resources were redeployed and private contributions were continued. IMPLICATIONS FOR POLICY AND RESEARCH: Given the substantial problems associated with the two-tiered American approach to mental health care, further consideration and analyses of the feasibility of public and private integration are suggested. Given the complexity of this effort, much more sophisticated analysis is needed. However, given the possibility that sufficient resources may now be available to accomplish integration, further work is suggested.

Evaluation of a linked service model of care for HIV-positive, homeless, and at-risk youths.

Two instruments were used to evaluate an agency's type and availability of services for HIV-positive and at-risk adolescents, and to assess opinions concerning healthcare referral patterns. These instruments were administered to representatives of 22 agencies from 10 categories of healthcare services. Nonmetric multidimensional scaling was used to model ratings of interagency knowledge, referral patterns, and general satisfaction with services. We found that no agencies offered youth services for inpatient adolescent-specific mental health treatment or short-term residential drug treatment; however, few offered long-term residential substance abuse detoxification services (5%), outpatient drug maintenance (5%), HIV-specific inpatient services (9%), intensive day treatment for substance abusers (9%), HIV home care (14%), HIV hospice care (14%), inpatient medical services (14%), short-term shelters (14%), long-term housing (18%), HIV-specific clinical trials (18%), and dental services (23%). Barriers to expanding care included lack of funding, transportation, and lack of awareness among youths about services. A multidimensional scaling analysis identified a tight service cluster of two community health centers and the largest public hospital serving poor communities of color, as well as a relatively tight cluster of three service agencies located on the Boston Common serving homeless youths. A third service cluster consisted of two university-affiliated medical centers and one community health center. In conclusion, we found that many critical services for HIV-positive youths are relatively scarce. Multidimensional scaling provides a visual presentation of the relationships of network sites. This evaluation of services indicates a need for increased, accessible youth-oriented HIV services and suggests that linkages across the three distinct clusters of service providers should be solidified. These methodologies can be used to develop a generic model describing the stages of linkage formation in HIV care service networks.

IS ADOPTION A RISK FACTOR FOR THE DEVELOPMENT OF ADJUSTMENT PROBLEMS?

The extent to which being adopted increases a child's risk for the development of adjustment problems has been debated for decades. Results from studies examining prevalence of adopted children and adolescents in outpatient and inpatient mental health treatment suggest that the risk associated with adoption is modest or nonexistent. This body of research is reviewed and critiqued. Two possible explanations for the apparent disparate findings of the clinically based and nonclinically based studies are explored: biases in referral for mental health treatment and the influence of the shape of the distribution of adjustment problems in the adopted and nonadopted populations. Implications for clinical practice and future research are explored.

Influence of patient and hospital factors on consumer satisfaction with inpatient mental health treatment.

This study examines patient- and facility-related determinants of satisfaction with inpatient mental health services. A random sample of veterans discharged from Department of Veterans Affairs inpatient units with primary diagnoses of a psychiatric or substance use disorder (N = 13,574) were mailed a 73-item questionnaire that addressed aspects of their recent hospital experience. Multiple regression analysis was used to evaluate the relationship between patient and hospital characteristics and both the likelihood of responding to the survey and aspects of satisfaction measured by 14 subscales. A total of 4,968 veterans, or 37 percent, mailed back responses to the questionnaire. Respondents were older than nonrespondents and were more likely to be white and married and to have nonpsychotic disorders other than substance use disorders. The strongest and most consistent predictors of satisfaction were older age and better self-reported health. Longer length of stay was also associated with greater satisfaction on a majority of subscales. Findings among female and minority veterans were mixed across measures. Large facilities and facilities that specialize in mental health treatment had lower levels of satisfaction than others. Patient characteristics accounted for more of the variance in satisfaction than did facility characteristics. Older and healthier patients reported greater satisfaction with mental health care services. Accurate comparison of patient satisfaction between facilities requires that adjustments be made for differences in patient characteristics. Large facilities may need to make special efforts to personalize their services.

Saleem Shah: His national and international contributions to forensic mental health systems.

Saleem Shah's work in shaping public sector forensic mental health systems and institutions was a major part of his career, occupying perhaps 10%-20% of his total time commitments. That work primarily consisted of two activities: One was Saleem's many site visits, consultations, planning and writing activities meant to improve inpatient forensic mental health facilities and treatment of mentally disordered offenders throughout the U.S. The other activity was his involvement in persons and systems, both forensic and civil, across international boundaries. Saleem's intellectual and practical insights informed government officials, administrators, physicians, and psychiatrists in the former Soviet Union, China, and India (where he was raised), as well as many other countries. Through work with the World Health Organization (WHO), Saleem also critiqued and helped develop mental health legislation and treatment systems in many countries. Following completion of his Ph.D. in 1957 at Pennsylvania State University, Saleem worked at the Spring Grove State Hospital as a psychology intern, and at the Allegany County Mental Health Clinic in Cumberland, Maryland. Then for

Utah's Prepaid Mental Health Plan: the First Year

This DataWatch analyzes the effect of the Utah Prepaid Mental Health Plan (UPMHP) on use of mental health services by and mental health treatment expenditures for Medicaid beneficiaries from July 1991 to June 1992. During this period three community mental health centers (CMHCs) provided mental health services to Medicaid beneficiaries in their catchment areas in return for capitated payments. Utilization and expenditure rates per beneficiary per month were analyzed using a "fixed-effects" statistical modeling approach, controlling for categories of beneficiary, time trends, seasonal effects, and CMHC grouping (capitated urban, capitated rural, noncapitated urban, and noncapitated rural). The results of the analysis suggest that the UPMHP reduced admissions for inpatient mental health treatment, inpatient mental health expenditures, and total mental health expenditures for Medicaid beneficiaries. These findings must be regarded as preliminary because of the relatively short time period covered by the data.

The effectiveness of day hospital treatment: a review.

Variability between day hospital programs in goals of treatment, administrative affiliation, staff, patients, and treatment modalities make generalizations concerning the effectiveness of treatment difficult, if not impossible. However, the available reports of evaluation of day hospital effectiveness suggest that such treatment is comparable to both inpatient and outpatient mental health treatment in effecting symptomatic and social change and these effects may be more long-lasting than those obtained in the more traditional treatment settings. Moreover, day hospital treatment may, probably because it provides an alternative to hospitalization, reduce the likelihood of hospitalization following discharge from treatment.